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Skincare for asylum seekers, refugees and immigrants

Sara Burr
BN(Hons) RN ENB N18 DipTropNursing C&G730
Freelance Dermatology Nurse

Reducing inequalities in health and health provision is a key theme underpinning the NHS Plan and the National Service Frameworks. Primary care has a strong role to play in tackling this agenda, providing services that reach those in greatest need.(1)
The complexity of dealing with the health problems of migrant populations is increasing. For those living with chronic skin disease it can be an even bigger issue, with access to washing facilities often limited. For others, the development of skin disease as a result of their situation can be significant - for example, scabies from overcrowded living spaces.
Several government reports have outlined the lack of training and services available in primary care for GPs and community nurses to manage patients with skin disease.(2,3) The evidence received from these reports maintains that skin disease should be better managed in primary care but is hindered by the continued lack of appropriate training within that setting. Many elderly patients and those without family or social support networks are those in greatest need. Hard-to-reach groups, including sex workers, drug and substance misusers, travellers, rough sleepers, ethnic minorities, asylum seekers, refugees and others who are at risk of exclusion are also in great need. 
The Department of Health's Health Inequalities Unit is starting to focus on improving access to primary healthcare services for hard-to-reach groups, but no emphasis to date has been placed upon the specific skincare needs of these people.

Health needs
Throughout the stages of transition that most migrant people experience on leaving their homeland (see Table 1), any ongoing or chronic health needs can often be neglected. Preventative care is not seen as a priority; survival is. When something does need attention, people will often present to the healthcare system as an emergency and may then require hospitalisation. Sometimes the condition could have been easily treated at an earlier stage, such as uncontrolled diabetic hypo- or hyperglycaemia or a flare of infected atopic eczema. In the UK it is estimated that 1 in 6 refugees lives with a physical problem severe enough that it prevents them from carrying out daily activities, and that two- thirds of refugees experience anxiety and depression.(4) Much could be done to alleviate this distress.

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Currently asylum seekers have free access to the NHS, including prescriptions and dental/optical care. However, the health minister put an end to failed asylum seekers receiving free healthcare in the UK in December 2003. So, what will they do while still in the country and maybe needing healthcare before going somewhere else?
Those who do use the services often place huge demands on GP time. This time is often a result of communication difficulties, poor interpreter and advocacy services, uncommon health problems and a lack of culturally relevant health education materials.

Skin disease in migrant populations
The skin forms a protective barrier between the internal (our body) and external environments. The skin will be influenced by many factors, and if we look at each of these in turn we can see how skin problems can easily become a problem for migrant populations.

Macroclimate
The geographical context of a country/region can significantly affect the skin's integrity. Changes in the temperature, rainfall, humidity, sun, wind and altitude can all lead to the development or worsening of existing skin problems. One effect of this is a drying out of the skin through evaporation of skin moisture from the wind and sun, which results in cracks and fissures.
An increase in altitude leads to a thinner atmosphere, allowing higher solar radiation on the skin, again drying it out, but also contributing to accumulated sun damage and potential skin cancer.
High humidity, as in the tropics, causes the opposite effect, and skin can become soggy and macerate, making it more prone to bacterial and fungal infections, particularly affecting the feet. Treatment of the affected skin will be to put the moisture back into the skin with emollients, or to allow it to dry out if macerated.

Microclimate
The individual's own environment plays a surprising part in the development of skin problems. Racial background and social status in the community will both affect the skin in some way. Caucasian skin (white skin type I or II), for example, has less melanin and is more susceptible to sun damage. Congroid skin (black skin type IV), conversely, has a low incidence of skin cancer but is more susceptible to leprosy.
The type of work, diet and housing will reflect the individual's socioeconomic status. Overcrowded living conditions can lead to infestations such as scabies and bacterial infections such as impetigo. Contact dermatitis can develop from manual work such as building or fruit picking. Dry skin or seborrhoeic dermatitis can be a result of physical stress on the body or of vitamin B12 deficiency. Management of these community-related conditions needs to be focused on education around the transmission of the infestation or infection, avoidance of, or protection from, irritating substances in the workplace, appropriate hygiene and the use of topical agents to manage them. Permethrin or malathion are used for scabies, and topical antibiotics such as fusidic acid or mupirocin for impetigo. However, it should be noted that there is increasing evidence of fusidic acid-resistant Staphylococcus aureus in some patients.(5,6) If possible, topical antiseptic preparations should be used to treat skin infection.(5) Emollients such as Diprobase (Schering-Plough), E45 (Crookes) or Eucerin (Beiersdorf) will be necessary for dry skin, antifungals such as ketoconazole for seborrhoeic dermatitis and dietary advice for vitamin deficiency.

Nursing assessment
The skills of nursing assessment, planning and intervention remain central to helping people with skin disease. A great deal can be done by exploring the individual's daily routine as well as what over-the-counter treatments they may use already, and how they can be made the most of or changed if necessary. Much of the help needed will also involve liaising with social service providers and other healthcare professionals to address the access refugees have to safe housing, appropriate work environments and financial support.

Barriers to nursing input
Barriers can exist for all healthcare professionals when dealing with skincare. Nurses may be in a better position to work through them with the time and resources available to them. These barriers include:

  • Different languages and availability of ­interpretation services.
  • Use of family members for interpretation and issues of confidentiality.
  • Understanding of appointment/healthcare system.
  • Limited ability for patient to express themselves verbally due to anxiety/emotions.
  • Cultural barriers: beliefs about pain, cause of ­disease, distrust of and unfamiliarity of Western medicine, misinterpreting side-effects, folk ­remedies, healthcare professionals' ignorance.

An understanding of the relevant culture for each group is vital when working with refugees. Taking time to investigate the meaning behind certain behaviours can help adjust the care given so it is appropriate. For example, asking their opinion about the condition and addressing the oldest member of the group first will be important when helping those from South East Asia. Checking on the preferred name when addressing Muslims will show respect. Is the head considered sacred and touching the feet considered an insult, as the lowest part of the body? The area between the waist and knees can be considered private, and so examination can be humiliating. Maybe there is a high expectation to be gained from intramuscular injections and so the need for these needs to be explored? Compromise may be needed from both sides to allow for safe practice.

Conclusion
The movement of millions of people around the world is increasing for a variety of reasons. Whatever contact nurses have with refugees, asylum seekers or immigrants, the fundamental appreciation of their holistic needs as human beings should be paramount. Issues around assessment, communication, cultural negotiation, establishing rapport and respect, sensitivity and safety are the basis for a therapeutic relationship with the client. The healthcare needs of these groups will include the impact that cultural practices and religious beliefs have. The transition and possible trauma they have gone through in getting to the UK can affect health in general as well as the skin integrity.
Much can be done on a simple preventative and health promotion level to help migrant populations care for their skin. Nurses are in an excellent position to do this, and the resources available to help address skincare needs are increasing all the time.

References

  1. Department of Health. Addressing inequalities - reaching the hard to reach groups. London: Department of Health/TSO; 2004.
  2. Associate Parliamentary Group on Skin. Report on the inquiry into skin diseases in elderly people. London: APGS; 2000.
  3. Associate Parliamentary Group on Skin 2002. Report on the enquiry into primary care dermatology ­services. London:APGS; 2002.
  4. Carey-Wood J, et al. The ­settlement of refugees in Britain. London: HMSO; 1995.p. 141.
  5. Shah M, Mohanraj M.Br J Dermatol 2003;148:1018-20.
  6. Weston VC, et al. BMJ 2002;324:1394.

Resources
British Dermatological Nursing Group
W:www.bdng.org.uk  
Dermatology Nurses Association
W:www.dnanurse.org  
Doctoronline
W:www.doctoronline.nhs.uk
National Eczema Society
W:www.eczema.org
NHS Direct
www.nhsdirect.nhs.uk